Every finding on record at Marjorie P Lee Retirement Community

Based on observation, record review, interview, and review of facility policy, the facility failed to store food items in a sanitary manner, failed to ensure proper hair covering was maintained in the kitchen, and failed to maintain the kitchen in a sanitary manner. This had the potential to affect all 71 residents who were identified as receiving food from the kitchen. Facility census was 71.Findings Include:Observation of walk-in freezer in the main kitchen area on 01/27/26 at 9:23 A.M. revealed open bags of plant-based meatballs and hamburger patties that were in unsealed bags, open to air and undated. These findings were confirmed in a concurrent interview with the Dining Service Director (DSD) #310. Observation of stand-up refrigerator in the main kitchen area on 01/27/26 at 9:28 A.M., revealed a half gallon of whole milk open and undated, one container of prune juice, one container of cranberry juice both open an undated. On the bottom shelf of the refrigerator was a box of single serve cranberry juices all with expiration dates of 01/26/26. These findings were confirmed in a concurrent interview with DSD #310. Observation of the facility's food storage area on 01/27/26 at 9:43 A.M. in the basement of the building revealed two boxes of multiple large bags of vanilla pudding mix all with expiration dates of 08/01/2022. This was confirmed in a concurrent interview with Dietary Service (DS) #34. DS #34 revealed kitchen staff no longer use the pudding mixes as they purchase pre-prepared vanilla pudding in cans to serve the residents. Observation of the walk-in freezer in the basement on 01/27/26 at 9:54 A.M. revealed a box of vegetable egg rolls in an open undated unsealed bag, a box of beef hoagie patties opened in an unsealed, undated bag, and a box of cod filets with one of two bags, opened in an unsealed bag undated with three cod filets in the bag. These findings were confirmed in a concurrent interview with DS #34. Observation of the Amstein House resident refrigerator/freezer on 01/28/26 at 12:57 P.M. revealed two bowls of ice cream covered but undated, which were confirmed and disposed of by Licensed Practical Nurse (LPN) #292. These findings were confirmed in a concurrent interview with Observation of Berghamer House resident refrigerator/freezer on 01/28/26 at 3:04 P.M. revealed no thermostat in the freezer compartment. In the refrigerator there was a container of mayonnaise with an expiration date of 09/16/25 and a jar of apple butter with an expiration date of 11/19/25. These findings were confirmed in a concurrent interview with LPN #208. Observation of lunch preparation and service on 01/29/2026 between 10:50 A.M. and 12:15 P.M. in the main kitchen revealed Specialty [NAME] (SC) #76, did not wear a beard guard during initial preparation of pureed meal. Observation revealed DS #34 was in the food preparation area without a beard guard in place. Dining Services Director #310 entered and moved about the food preparation area of the kitchen without a hair net on. In addition, DS #242 was observed entering and exiting the food preparation are of the kitchen during lunch service without a hair net or beard guard in place. An interview on 01/29/2026 at 10:50 A.M. with SC #76 confirmed SC #76 was not wearing a beard guard when beginning to prepare a pureed meal. An interview on 01/292/206 at 12:04 P.M. with DSD #310 confirmed DS #34 was in the food preparation area without a beard guard in place. Further interview with DSD #310 confirmed DSD #310 entered the food preparation are of the kitchen without a hair net in place, and DS #242 was in the food preparation are of the kitchen without a hair net or beard guard in place. Observation of lunch preparation and service on 01/29/2026 between 10:50 A.M. and 12:15 P.M. in the main kitchen revealed SC #76 had his personal cell phone and charging cord plugged into an outlet and sitting on the food preparation counter in the main kitchen. Interview on 01/29/2026 10:50 A.M. and 12:15 P.M. with SC #76 confirmed his cell phone was sitting on a food preparation surface in the kitchen while preparing a pureed meal and his cell phone should not be on a food preparation surface. Interview on 01/29/2026 at 2:07 P.M. with Hospitality Director (HD) #488 revealed the facility did not have a written policy concerning keeping personal items off of food preparation surfaces. Observation of lunch preparation and service on 01/29/2026 between 10:50 A.M. and 12:15 P.M. revealed a darkly colored fuzz hanging from the ceiling in several food preparation areas of the main kitchen. Interview on 01/29/2026 between 10:50 A.M. and 11:13 A.M. with SC #76 confirmed a darkly colored fuzz hanging from the ceiling in several food preparation areas of the main kitchen. Interview on 01/29/2026 at 11:13 A.M. with DS #34 confirmed a darkly colored fuzz hanging from the ceiling in several food preparation areas of the main kitchen. Further interview with DS #34 revealed maintenance is responsible for the cleaning of the ceiling in the kitchen preparation areas and the ceiling was cleaned a few months ago. Interview on 01/29/2026 at 2:07 P.M. with HD #488 revealed the facility did not have a written policy concerning maintaining the cleanliness of the kitchen preparation area. Observation on 01/29/2026 from 12:15 P.M. to 12:45 P.M. of the Berghamer kitchen serving area revealed that Specialty [NAME] (SC) #60 used the same alcohol wipe to clean the thermometer between checking temperatures for the soup, philly steak meat, peppers, and mashed potatoes. Interview on 01/29/2026 between 12:15 P.M. and 12:45 P.M. with SC #60 verified a new alcohol wipe was not used to clean the thermometer between checking temperatures for the soup, philly steak meat, peppers, and mashed potatoes. Further interview with SC #60 revealed a new alcohol wipe should have been used to clean the thermometer between each food item. Review of a facility policy and procedure with the subject Infection Control Guidelines related to Dining Services with an effective date of 05/28/2000 stated Dining Services staff are responsible for wearing the appropriate PPE given the task they are performing. Additional review of this policy revealed, All Dining Services Staff will abide by city and state Board of Health regulations pertaining to sanitation and infection control.

Based on observation, record review, staff interview, and facility policy review, the facility failed to prepare pureed foods to ensure nutritive value and palatability were maintained. This affected one resident, (#13) who was identified as the only resident in the facility who require a pureed diet. The facility census was 71.Findings Include:Review of Resident #13's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including dementia with behavioral disturbance, malnutrition, urinary retention, anxiety disorder, depression, chronic constipation, atherosclerotic heart disease and osteoporosis.Review of Resident #13's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired, and was dependent for all activities of daily living including bed mobility and transfers. Resident #13 required a mechanically altered diet and had significant weight loss in the last quarter. Resident #13 received hospice care.Observation of the kitchen on 01/29/2026 from 10:50 A.M. to 11:13 A.M. revealed Specialty [NAME] (SC) #76 added an unmeasured amount of water as a thinning agent while preparing the pureed philly steak sandwich with provolone, onions, and peppers.Interview on 01/29/2026 from 10:50 A.M. to 11:13 A.M. with SC #76 confirmed water was utilized as a thinning agent in the puree preparation. SC #76 further reported he was not following a documented recipe or procedure to make the pureed meal.During an interview on 01/29/2026 at 11:30 A.M. Dining Services Director (DSD) #310 reported beef broth should have been used as a thinning agent to puree the philly steak sandwich with provolone, onions, and peppers. DSD #310 confirmed that water should not have been used as a thinning agent in making the puree. DSD #310 confirmed there was no specific recipe available for direction on how to prepare a pureed philly steak sandwich with provolone, onions, and peppers.Review of an undated and untitled policy and procedure with the identified purpose To create high quality and good tasting purred meals for the residents, stated blend using broth, juice or milk depending on what is appropriate for the food item, see recipe for the proper amount of liquid to be used.

Based on observation, interview and record review, the facility failed to ensure enhanced barrier precautions were implemented for one, Resident #13. This affected one of one resident reviewed for enhanced barrier precautions. Facility census was 71. Findings Include:Review of medical record for Resident #13 revealed an admission date of 02/26/21. Diagnoses included dementia with behavioral disturbance, malnutrition, urinary retention, anxiety disorder, depression, chronic constipation, atherosclerotic heart disease and osteoporosis.Resident #13's Minimum Data Set (MDS) assessment dated [DATE] revealed resident was severely cognitively impaired, was dependent for all activities of daily living including bed mobility and transfers. Resident #13 was coded as incontinent of bowel and bladder and is dependent for all incontinence care. Resident #13 is on a mechanically altered diet and had significant weight loss in the last quarter. Resident #13 was under hospice care.Review of progress note dated 01/12/26 by Wound Nurse #490 revealed Resident #13 had areas of Moisture Associated Skin Damage (MASD)/mechanical irritation on the left upper buttock/sacrum. Review of progress note dated 01/19/26 by Wound Nurse #432 revealed the wound nurse discovered an unstageable pressure ulcer over sacrum which measured 3.5 centimeters (cm) x 0.1 cm, with 75% slough and 25% granulation. Wound Nurse #348 revealed development of the pressure ulcer was unavoidable secondary to Resident #13's overall decline.Interview with Licensed Practical Nurse (LPN) #292 on 01/28/26 at 10:37 A.M. revealed no residents on the long term care dementia unit had catheters, enteral nutrition or wounds. She confirmed no resident was currently on Enhanced Barrier Precautions (EBP).Interview with Care Team Manager (CTM)/LPN #114 on 01/28/26 at 1:08 P.M. confirmed the long-term care dementia unit had no residents on EPB. CTM/LPN #114 confirmed that Resident #13 lived on the long term care dementia unit, had an open wound and should have been on EPB.Review of facility policy titled Enhanced Barrier Precautions dated 07/31/25, revealed residents with wounds, indwelling medical devices (e.g., urinary catheters, tracheostomies, feeding tubes) or those who are ventilator dependent, even if known to be colonized are all required to be in EPB.

Based on medical record review, review of the facility incident report, review of Root Cause Analysis report, hospital record review, resident, visitor, and staff interviews, review of personnel file, and policy review, the facility failed to ensure a resident was positioned safely during personal care. This resulted in Actual Harm to Resident #10 on 02/16/25 when Certified Nursing Assistant (CNA) #150 did not position Resident #10 correctly while providing personal care in bed and did not call for assistance prior to moving the bed when the resident was in a compromised position resulting in Resident #10 sustaining a left hip fracture, a small scalp laceration to the front top of her head, an abrasion to the right forearm, and a bruise with eye bleed to the left eye. This affected one (Resident #10) of three residents reviewed for falls. The facility census was 73. Findings include: Review of the medical record revealed Resident #10 was admitted to the facility on [DATE]. Diagnoses included fracture of unspecified part of the neck of the left femur, vascular dementia, injury of the head, hemiplegia affecting the left non-dominant side, and acute on chronic diastolic heart failure. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #10 had severely impaired cognition, had no behaviors, did not reject care, and did not wander. Resident #10 was dependent on staff for activities of daily living (ADL) care and required transfers with a mechanical lift. Review of the care plan dated 04/03/25 revealed Resident #10 was at risk for falls due to history of cerebral infarction with left-sided hemiplegia, need for assistance, and recent admission from a different facility. Resident #10 had a fall on 02/16/25. Interventions included two-person assistance with transfers and turning/repositioning in bed status post fall on 02/16/25. Resident #10 returned from the hospital on 02/20/25 with a fracture of unspecified part of neck of left femur, subsequent encounter for closed fracture with routine healing. Interventions included bolsters to bed (placed 02/24/25), provide toileting as needed, evaluate the need for positioning alarms, provide increased supervision according to needs, assess and treat orthostatic hypotension, and comprehensive medication review for polypharmacy and medications that increase fall risk. Review of the progress note dated 02/16/25 at 12:52 P.M. revealed CNA #150 reported at 10:10 A.M. that Resident #10 fell out of bed. Resident #10 was lying on the floor, diagonally in room, head towards window and feet towards the bathroom, and pillow under her head. CNA #150 stated he was in the process of turning her toward the wall to place the brief under her when she slipped between the bed and the wall. CNA #150 stated the bed was locked, he moved her left foot over her right when she began to slip, and he lowered her down the best he could. Resident #10 was noted with a small 1.0-centimeter (cm) abrasion to top of the head, bleeding a small amount of bright red blood, and an intact abrasion to right forearm. Four staff members assisted Resident #10 with a Hoyer lift after placing brief on her. Neuro checks were initiated. Resident #10 had a small blood vessel in the left eye (at 5 o'clock compared to pupil), was noted to be bleeding from a small scalp wound, and had a bruise noted to be coming out under and outer to left eyelid. The nurse notified the management staff and family. The on-call provider was called and gave orders to send out to emergency room (ER) for computed tomography (CT) scan due to Resident #10 was on the blood thinner, Eliquis. Resident#10 left the facility to go to the ER at 11:55 A.M. Review of hospital documentation revealed general examination on 02/16/25 at 3:15 P.M. showed mild swelling of the left thigh and hip with minimal shortening of the left lower extremity noted. X-ray imaging showed displaced fracture of the left femoral neck. Review of the facility's investigation dated 02/18/25 at 1:52 P.M. revealed Nurse Manager #132 concluded Resident #10 was dependent on staff for assistance with care and transfers. CNA #150 provided care to Resident #10 while she was in bed on a low air loss mattress. The bed was locked and was at waist level for CNA#150 to properly provide care. CNA #150 rolled Resident #10 over towards the wall when the resident's legs began to slide off the edge of the bed. CNA #150 attempted to pull the resident over by her legs but was unsuccessful. CNA #150 then unlocked the bed to move it away from the wall so he could get in to assist the resident, but that caused the resident to fall off the bed and onto the floor. Review of CNA #150's witness statement dated 02/18/25 revealed he rolled Resident #10 over in the bed towards the wall. Resident #10 had her right hand holding the rail and a pillow under her left hand. CNA #150 stated her leg was crossed over the other leg, and her leg was falling off the bed. At this time, the resident's face was against the handrail. CNA #150 stated he tried to pull the resident over with her legs but was unable to. CNA #150 did not want to pull on her upper body/shoulder due to a previous injury. CNA #150 stated when he couldn't get her pulled over by the legs, he then went to the foot of the bed, unlocked the bed, and moved it over to be able to assist her. When CNA #150 moved the bed, the resident's bottom half of her body started to fall onto the floor. CNA #150 stated he intervened by grabbing her upper body, protecting her head, and lowering her the rest of the way to the floor. CNA #150 stated he assisted the resident in lying on the floor and placed a pillow under her head. CNA #150 then went to get help. Review of the document titled ERS Critical Incidences Root Cause Analysis 2025 dated 02/26/15 revealed in summary: CNA #150 informed the nurse at approximately 10:10 A.M. that Resident #10 had fallen out of bed. Resident #10 was noted to be laying on the floor, diagonally in room, head towards window and feet towards bathroom, with pillows under her head supporting her. CNA #150 stated he was in the process of turning her toward the wall to place the brief under her when she slipped between the bed and the wall. CNA #150 stated the bed was locked, he moved her left foot over her right when she began to slip, and he lowered her down the best he could. The nurse notified management and family. The on-call provider was called and gave orders to send out to ER for CT scan due to Resident #10 being on a blood thinner, Eliquis. Resident#10 left the facility to go to the ER at 11:55 A.M. The hospital performed a whole-body scan and discovered a fracture on the left-hip. An additional review of Timeline and Causal Factor Chart revealed CNA #150 was performing morning care with Resident #10 in bed. CNA #150 turned resident onto her right side towards the wall. The bed was locked. Resident #10's legs began to fall off the bed. CNA #150 unlocked the bed to get to the resident. While moving the bed, the resident's lower torso fell off the bed, due to gravity. CNA #150 then lowered her upper torso onto floor and notified the nurse that resident was on the floor. It was noted that CNA #150 did not position the resident correctly prior to turning, and CNA #150 did not call for assistance in a compromising situation but attempted to address on his own. The root cause of the fall was assessed to be human error: the CNA did not position Resident #10 correctly while providing personal care in bed, did not follow procedure, and did not call for assistance prior to moving the bed when the resident was in a compromised position. Review of the personnel file revealed CNA #150 was hired on 08/23/22 and was terminated on 03/24/25. Review of the Corrective Counseling notice dated 03/24/25 revealed CNA#150 was terminated on 03/24/25 related to meal documentation discrepancies and for putting the health and wellbeing of Resident #10 in jeopardy on 02/16/25 after failing to provide proper positioning in bed while providing care and failing to call for assistance resulting in a fall with injury to the resident. During an interview on 04/04/25 at 10:42 A.M., the Director of Nursing (DON) stated Resident #10 was sent to the hospital after a fall on 02/16/25 to be evaluated for a bleeding scalp laceration because she was on blood thinners. The hospital informed the facility Resident #10 had a hip fracture. The facility completed an incident report and root cause analysis which indicated the fall was caused by human error. CNA #150 had not positioned Resident #10 appropriately prior to turning her in bed and failed to call for assistance before unlocking the bed. When Resident #10 started to slide out, CNA #150 attempted to get between the bed and the wall to assist with lowering her to the floor. As Resident #10 went down, Resident #10 scraped her head on the arm rail and had a small abrasion that was bleeding. After the fall incident with Resident #10 on 02/16/25, the DON stated no other residents were assessed for fall interventions; no other audits were completed except the facility audited to ensure the bolsters were in place on Resident #10's bed when Resident #10 returned from the hospital; All nursing staff were educated about proper positioning of the resident in bed during care with return demonstration. During concurrent interviews on 04/04/25 at 2:10 P.M., Resident #10 stated she was ok and indicated she was still having pain related to the fall. A family friend at bedside stated that since the fall, Resident #10 has increased pain, had become less communicative, and had increased memory lapses. The visitor stated prior to the fall; the family was looking forward to bringing the resident home but were no longer sure due to increased care needs related to the fall. Review of the policy titled Fall Prevention and Management Protocol dated 02/23/21 revealed residents were assessed for risk factor for falling and the interdisciplinary team developed a plan for services to reduce the resident's risk for falls. This deficiency represents noncompliance investigated under Complaint Number OH00162748.

Based on observation, interview, review of the Ohio Food Code and policy review, the facility failed to ensure hair nets were worn and food items were maintained in a manner to prevent and protect food against contamination and spoilage. This affected all residents residing in the facility. The facility census was 48. Findings include: Observation of the kitchen on 10/09/18 at 10:00 A.M. revealed a carton of half and half to be open without a lid on it located in the reach in refrigerator, an undated pan of olives that were covered with plastic wrap in the reach in refrigerator, an undated plate of cream cheese that was covered with plastic wrap in the reach in refrigerator, a bottle of Worcestershire sauce that was open without a lid sitting on a shelf in the kitchen and three boxes of opened undated scrambled eggs box mixes in the walk in refrigerator. Interview with Dining Services Supervisor #64 at the time of the observation verified the above findings. Observation of the walk-in freezer in the basement on 10/09/18 at 10:10 A.M. revealed a tub of ice cream with a smashed in lid exposing the ice cream. Interview with Dining Services Supervisor #7 at the time of the observation verified the above finding. Observation of the kitchen on 10/10/18 at 11:53 A.M. revealed staff members including Housekeeper #75, Housekeeper #78, Housekeeper #115, Housekeeper #144, and Housekeeper #178 to enter the kitchen without hair nets. Housekeeper #78 and Housekeeper #144 were observed to come around the back of the salad bar located in the kitchen to get items from the salad bar without using hair nets. Housekeeper #144 and Housekeeper #178 were also observed to go back towards the cooking area when exiting the kitchen. Staff members were also observed removing and placing plastic covers on the food items in the salad bar without gloves. Interview with Cook #105 at the time of the observation verified the finding of the staff members not having hair nets in the kitchen. Cook #105 reported staff members go into the kitchen to get on the elevator located in the kitchen across from the cooking area. Cook #105 also reported the salad bar in the kitchen was used for residents. Interview with Dining Services Supervisor #64 on 10/10/18 at 12:00 P.M. verified staff members were in the kitchen without hair nets. Dining Services Supervisor #64 also verified staff members were removing and placing plastic covers on the food in the salad bar without gloves. Interview with Dining Services Manager #166 on 10/10/18 at 2:40 P.M. revealed the facility did not have a policy on food storage or the use of hair nets. Dining Services Manager #166 reported the facility practices are based on the (YEAR) version of the Ohio Food Code. Review of a list of diets in the facility revealed the facility did not have any residents that were no food by mouth (NPO). Review of the (YEAR) version of the Ohio Food Code revealed food employees should effectively restrain hair or wear hair restrains and food should be kept in covered containers or wrappings. Review of the facility's Labeling and Dating policy dated 03/13/03 revealed all food items will be marked with the date they were opened or prepared.

Based on record review, observation, interviews and policy review, the facility failed to ensure a resident's anti-coagulant medication was provided without a lapse in receiving the medication. This affected one (#11) of six residents reviewed for unnecessary medications. The facility census was 48. Findings include: Record review revealed Resident #11 was admitted to the facility on [DATE] with the following diagnoses; [MEDICAL CONDITION] embolism, age related [MEDICAL CONDITION], essential primary hypertension, [MEDICAL CONDITIONS], megaloblastic [MEDICAL CONDITION], dementia with behavioral disturbance, shortness of breath, chest pain, and [MEDICAL CONDITION]. Review of Resident #11's admission Minimum Data Sets (MDS) assessment dated [DATE] revealed the resident had moderate cognitive impairment. Further review of the MDS revealed the resident required extensive assistance with bed mobility, transfers, dressing, and eating and total dependence with toileting and personal hygiene. Review of Resident 11's physician's orders [REDACTED]. Review of Resident #11's Medication Administration Report (MAR) revealed the resident was not given his Eliquis five mg one tablet by mouth two times daily for [MEDICAL CONDITION] embolism on 10/02/18 at 9:00 P.M., 10/03/18 at 9:00 P.M., 10/04/18 at 900 A.M., 10/05/18 at 900 A.M. and 9:00 P.M., 10/06/18 at 9:00 P.M., 10/07/18 at 9:00 A.M. and 9:00 P.M., 10/08/18 at 9:00 A.M. and 10/09/18 at 9:00 A.M. Review of Resident #11's progress notes from 09/30/18 to 10/10/18 revealed no documentation regarding resident's Eliquis being out or any attempts to fill the medication. Interview on 10/09/18 at 3:38 P.M. with Resident #11's resident representative revealed the resident did not have his medication for five days due to the facility being unable to fill the medication at her pharmacy of choice. Observation of Resident #11's medication drawer on 10/10/18 at 5:00 P.M. revealed the resident had a bottle of Eliquis from Resident #11's pharmacy of choice dated 10/07/18. Interview with Registered Nurse (RN) #77 at the time of the observation verified the finding of the Eliquis bottle from Resident #11's pharmacy of choice dated 10/07/18. Interview with RN #77 on 10/11/18 at 8:34 A.M. verified Resident #11 did not have his Eliquis from 10/02/18 to 10/07/18 due to the medication not being at the facility. RN #77 reported the facility received notice on 09/28/18 from Resident #11's pharmacy of choice that an order was needed to refill the Eliquis. RN #77 reported the facility reached out to Physician #188 on 09/28/18, but the physician did not respond. RN #77 stated Resident #11 ran out of the Eliquis on 10/02/18. RN #77 stated Nurse Practitioner #189 was notified Resident #11 was out of Eliquis on 10/07/18 due to Physician #188 not responding to the request for an order. RN #77 reported NP #189 was able to call in a prescription on 10/07/18. RN #77 confirmed Resident #11's resident representative was able to pick up the resident's medication from his pharmacy of choice on 10/07/18. RN #77 also verified two Medication Aides (#36 and #145) reported they administered Resident #11's Eliquis 5 mg during the period of time the resident did not have Eliquis in the facility. RN #77 also stated Resident #11's Eliquis was not pulled from the emergency box. RN #77 reported the facility was investigating how the Resident #11's Eliquis 5 mg was given on 10/03/18 at 9:00 A.M., 10/04/18 at 9:00 P.M. and on 10/06/18 at 9:00 A.M. since the resident did not have any Eliquis in the facility. RN #77 also reported he did not know why Resident #11 did not receive his Eliquis on 10/08/18 at 9:00 P.M. and on 10/09/18 at 900 A.M. since the medication was back in the facility at that time. Interview with Medication Aide #145 on 10/11/18 at 12:13 P.M. revealed he did not remember giving Resident #11 his Eliquis 5 mg 10/04/18 at 9:00 P.M. and on 10/06/18 at 9:00 A.M Medication Aide #145 reported he was aware of a period of time that Resident #11 did not have his Eliquis in stock. Interview with Medication Aide #36 on 10/11/18 at 12:26 P.M., revealed she administered the resident's Eliquis on 10/03/18 at 9:00 A.M Phone interview with Physician #188's office on 10/11/18 at 12:32 P.M. revealed the physician was out of the office until 10/21/18. Phone interview with Physician #190 on 10/11/18 at 12:39 P.M. revealed he was unable to determine how Resident #11 could have been affected by not receiving his Eliquis from 10/02/18 to 10/07/18. Physician #190 reported he was not aware of any current serious impact to Resident #11 due to him not receiving his Eliquis. Physician #190 reported the possibility of the resident having a clot or issue as a result of him not taking his Eliquis was dependent on his family history and other factors that could have caused the first clot. Interview with the Director of Nursing (DON) on 10/11/18 at 3:30 P.M. reported the facility did not have a medication administration policy that addressed the accuracy of the MAR indicated [REDACTED]. Review of the facility's Medication Administration Scheduling policy dated 01/01/09 revealed no information regarding accuracy of the MAR indicated [REDACTED]

Based on record review and staff interview, the facility failed to ensure residents were provided with the required beneficiary notice in writing and in advance of discontinuing skilled Medicare part A services. This affected three (10, #21, and #207) of three residents reviewed for beneficiary protection notification. The facility census was 48. Findings include: 1. Review of Resident #10's medical record revealed the resident was admitted to the facility on [DATE] and continued to reside in the facility after Medicare Part A skilled services were discontinued. A Notice of Medicare Non-Coverage (NOMNC) indicated skilled Part A services would end on 07/18/18. The notice contained hand-written documentation that a verbal notification of discontinuation of services was provided to the resident's representative on 07/16/18. Neither the record nor the notice contained any evidence that a written notice was ever provided to the resident's representative. In addition, the medical record contained an Advanced Beneficiary Notice signed by the resident's representative and dated 07/19/18, indicating no advanced notice of discontinuation of Part A skilled services was provided. Interview on 10/10/18 at 3:03 P.M. with Discharge Planner (DP) #129 verified the resident remained in the facility after Part A skilled services were discontinued, that the medical record contained no evidence that the NOMNC was delivered in writing to the resident's representative, and that the Advanced Beneficiary Notice was signed by the resident's representative the day after skilled services ended, providing no advanced notice discontinuation of services. 2. Review of Resident #21's medical record revealed the resident was admitted to the facility on [DATE] and continued to reside in the facility after Medicare Part A skilled services were discontinued. The resident's record contained a NOMNC signed by the resident dated 09/17/18. The resident's record contained no evidence that the facility provided the resident or resident's representative with a written Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) letter. Interview on 10/10/18 at 3:03 P.M. with DP #129 verified the resident remained in the facility after Part A skilled services were discontinued and that the medical record contained no evidence that a written SNFABN was provided to the resident or representative. 3. Review of Resident #207's closed medical record revealed the resident was admitted to the facility on [DATE] and was discharged to home on 09/16/18. A NOMNC letter indicated skilled Part A services would end on 09/15/18. The NOMNC letter contained hand-written documentation that a verbal notification of discontinuation of services was provided to the resident's representative on 09/13/18. The medical record contained no evidence that a written notice was ever provided to the resident's representative. Interview on 10/10/18 at 3:03 P.M. with DP #129 verified the resident discharged to home on 09/16/18 and that the medical record contained no evidence that a NOMNC letter was ever provided in writing to the resident or resident's representative.

Based on medical record review and staff interview, the facility failed to ensure [MEDICAL CONDITION] medications ordered on an as needed basis were not prescribed for an indefinite period of time. This affected one (#193) of six residents reviewed for unnecessary medications. The facility census was 48. Resident # 193 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the comprehensive admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. The assessment documented the resident required extensive assistance for activities of daily living (ADLs) but required only limited assistance for eating. The assessment documented the resident received a hypnotic medication for seven days of the assessment period. Review of the admission physician's orders [REDACTED]. Review of the History and Physical signed and dated by the resident's physician on 09/23/18 did not address the resident's nightly use of Ambien. Review of the Medication Administration Records for 09/2018 and 10/2018 revealed the resident received [MEDICATION NAME] every night from 09/18/18 through 10/11/18, indicating 23 consecutive doses administered. Interview on 10/11/18 at 10:36 A.M. with Registered Nurse (RN) #92 verified [MEDICATION NAME] ordered 09/18/18 for as needed use, had no stop date, the History and Physical signed by the physician on 09/23/18 contained to rationale to continue the medication beyond the 14 day time duration limit, and that the resident received the medication every night since admission.

Based on record review and interview the facility failed to ensure the physician reviewed and accurately documented a resident's medications in the physician's progress notes. This affected one (#6) of six residents selected for medication review. The facility census was 48. Findings include: Record review revealed Resident #6 was admitted to the facility on [DATE] with the following diagnoses; type 2 diabetes, [MEDICAL CONDITION], dementia without behavioral disturbance, [MEDICAL CONDITION], Vitamin D deficiency, elevated white blood cell count, altered mental status, abnormal glucose, polyuria, cerebral infarction, constipation and hypertension. Review of Resident #6's quarterly Minimum Data Sets (MDSs) assessment dated [DATE] revealed the resident was cognitively impaired. Further review of Resident #6's MDS revealed the resident required supervision with bed mobility, transfers, dressing, eating and toileting and limited assistance with personal hygiene. Review of Resident #6's physician's orders [REDACTED]. Resident's [MEDICATION NAME] 5 milligrams (mg) daily was reinstated on 02/14/18. Review of Resident #6's progress notes revealed Resident #6's [MEDICATION NAME] 5 mg daily was reinstated on 02/14/18 per the request of the resident's family. Review of Resident #6's physician's progress note dated 02/13/18 revealed resident's Selective Serotonin Reuptake Inhibitor (SSRI) or [MEDICATION NAME] was decreased with no significant changes. The physician's progress note also reported the medication would be discontinued as a trial on 02/13/18. Review of Resident #6's physician's progress note dated 03/06/18 revealed resident's SSRI or [MEDICATION NAME] was discontinued and the resident's mood was good. Review of Resident #6's physician's progress note dated 04/03/18 revealed resident's SSRI or [MEDICATION NAME] was discontinued with no significant changes. Review of Resident #6's physician's progress note dated 05/08/18 revealed resident's SSRI or [MEDICATION NAME] was discontinued with no changes. Review of Resident #6's physician's progress note dated 06/05/18 revealed resident's SSRI or [MEDICATION NAME] was discontinued and resident's mood was good. Review of Resident #6's physician's progress note dated 08/07/18 revealed resident's SSRI or [MEDICATION NAME] was discontinued months ago with no changes in resident's mood. Interview on 10/10/18 at 4:24 P.M. with the Director of Nursing (DON) verified Resident #6's SSRI or [MEDICATION NAME] was discontinued on 02/13/18 and reinstated 02/14/18 per the family's request. The DON verified Resident #6's physician continued to document Resident #6's SSRI or [MEDICATION NAME] was discontinued in the physician's progress notes dated 02/13/18, 03/06/18, 04/03/18, 05/08/18, 06/05/18 and 08/07/18,despite the medication being reinstated on 02/14/18.

Based on record review, observation, interviews, and review of policy the facility failed to ensure a resident prescribed an anti-coagulant was free of significant medication errors. The resident missed 10 doses. This affected one (#11) of six residents reviewed for unnecessary medication review. The facility census was 48. Findings include: Record review revealed Resident #11 was admitted to the facility on [DATE] with the following diagnoses; [MEDICAL CONDITION] embolism, age related [MEDICAL CONDITION], essential primary hypertension, [MEDICAL CONDITIONS], megaloblastic [MEDICAL CONDITION], dementia with behavioral disturbance, shortness of breath, chest pain, and [MEDICAL CONDITION]. Review of Resident #11's admission Minimum Data Sets (MDS) assessment dated [DATE] revealed the resident had moderate cognitive impairment. Further review of the MDS revealed the resident required extensive assistance with bed mobility, transfers, dressing, and eating and total dependence with toileting and personal hygiene. Review of Resident 11's physician's orders [REDACTED]. Review of Resident #11's Medication Administration Report (MAR) revealed the resident was not given his Eliquis five mg one tablet by mouth two times daily for [MEDICAL CONDITION] embolism on 10/02/18 at 9:00 P.M., 10/03/18 at 9:00 P.M., 10/04/18 at 900 A.M., 10/05/18 at 900 A.M. and 9:00 P.M., 10/06/18 at 9:00 P.M., 10/07/18 at 9:00 A.M. and 9:00 P.M., 10/08/18 at 9:00 A.M. and 10/09/18 at 9:00 A.M. Review of Resident #11's progress notes from 09/30/18 to 10/10/18 revealed no documentation regarding resident's Eliquis being out or any attempts to fill the medication. Interview on 10/09/18 at 3:38 P.M. with Resident #11's resident representative revealed the resident did not have his medication for five days due to the facility being unable to fill the medication at her pharmacy of choice. Observation of Resident #11's medication drawer on 10/10/18 at 5:00 P.M. revealed the resident had a bottle of Eliquis from Resident #11's pharmacy of choice dated 10/07/18. Interview with Registered Nurse (RN) #77 at the time of the observation verified the finding of the Eliquis bottle from Resident #11's pharmacy of choice dated 10/07/18. Interview with RN #77 on 10/11/18 at 8:34 A.M. verified Resident #11 did not have his Eliquis from 10/02/18 to 10/07/18 due to the medication not being at the facility. RN #77 reported the facility received notice on 09/28/18 from Resident #11's pharmacy of choice that an order was needed to refill the Eliquis. RN #77 reported the facility reached out to Physician #188 on 09/28/18, but the physician did not respond. RN #77 stated Resident #11 ran out of the Eliquis on 10/02/18. RN #77 stated Nurse Practitioner #189 was notified Resident #11 was out of Eliquis on 10/07/18 due to Physician #188 not responding to the request for an order. RN #77 reported NP #189 was able to call in a prescription on 10/07/18. RN #77 confirmed Resident #11's resident representative was able to pick up the resident's medication from his pharmacy of choice on 10/07/18. RN #77 also verified two Medication Aides (#36 and #145) reported they administered Resident #11's Eliquis 5 mg during the period of time the resident did not have Eliquis in the facility. RN #77 also stated Resident #11's Eliquis was not pulled from the emergency box. RN #77 reported the facility was investigating how the Resident #11's Eliquis 5 mg was given on 10/03/18 at 9:00 A.M., 10/04/18 at 9:00 P.M. and on 10/06/18 at 9:00 A.M. since the resident did not have any Eliquis in the facility. RN #77 also reported he did not know why Resident #11 did not receive his Eliquis on 10/08/18 at 9:00 P.M. and on 10/09/18 at 900 A.M. since the medication was back in the facility at that time. Interview with Medication Aide #145 on 10/11/18 at 12:13 P.M. revealed he did not remember giving Resident #11 his Eliquis 5 mg 10/04/18 at 9:00 P.M. and on 10/06/18 at 9:00 A.M Medication Aide #145 reported he was aware of a period of time that Resident #11 did not have his Eliquis in stock. Interview with Medication Aide #36 on 10/11/18 at 12:26 P.M., revealed she administered the resident's Eliquis on 10/03/18 at 9:00 A.M Phone interview with Physician #188's office on 10/11/18 at 12:32 P.M. revealed the physician was out of the office until 10/21/18. Phone interview with Physician #190 on 10/11/18 at 12:39 P.M. revealed he was unable to determine how Resident #11 could have been affected by not receiving his Eliquis from 10/02/18 to 10/07/18. Physician #190 reported he was not aware of any current serious impact to Resident #11 due to him not receiving his Eliquis. Physician #190 reported the possibility of the resident having a clot or issue as a result of him not taking his Eliquis was dependent on his family history and other factors that could have caused the first clot. Interview with the Director of Nursing (DON) on 10/11/18 at 3:30 P.M. reported the facility did not have a medication administration policy that addressed the accuracy of the MAR indicated [REDACTED]. Review of the facility's Medication Administration Scheduling policy dated 01/01/09 revealed no information regarding accuracy of the MAR indicated [REDACTED]

Based on record review, interviews and policy review the facility failed to ensure a resident's code status and a resident's Medication Administration Record [REDACTED]. The facility census was 48. Findings include: 1. Record review revealed Resident #11 was admitted to the facility on [DATE] with the following diagnoses; [MEDICAL CONDITION] embolism, age related [MEDICAL CONDITION], essential primary hypertension, [MEDICAL CONDITIONS], megaloblastic [MEDICAL CONDITION], dementia with behavioral disturbance, shortness of breath, chest pain, and [MEDICAL CONDITION]. Review of Resident #11's admission Minimum Data Sets (MDS) assessment dated [DATE] revealed the resident had moderate cognitive impairment. Further review of the MDS revealed the resident required extensive assistance with bed mobility, transfers, dressing, and eating and total dependence with toileting and personal hygiene. Review of Resident 11's physician's orders [REDACTED]. Review of Resident #11's Medication Administration Report (MAR) revealed the resident was not given his Eliquis five mg one tablet by mouth two times daily for [MEDICAL CONDITION] embolism on 10/02/18 at 9:00 P.M., 10/03/18 at 9:00 P.M., 10/04/18 at 900 A.M., 10/05/18 at 900 A.M. and 9:00 P.M., 10/06/18 at 9:00 P.M., 10/07/18 at 9:00 A.M. and 9:00 P.M., 10/08/18 at 9:00 A.M. and 10/09/18 at 9:00 A.M. Review of Resident #11's progress notes from 09/30/18 to 10/10/18 revealed no documentation regarding resident's Eliquis being out or any attempts to fill the medication. Interview on 10/09/18 at 3:38 P.M. with Resident #11's resident representative revealed the resident did not have his medication for five days due to the facility being unable to fill the medication at her pharmacy of choice. Observation of Resident #11's medication drawer on 10/10/18 at 5:00 P.M. revealed the resident had a bottle of Eliquis from Resident #11's pharmacy of choice dated 10/07/18. Interview with Registered Nurse (RN) #77 at the time of the observation verified the finding of the Eliquis bottle from Resident #11's pharmacy of choice dated 10/07/18. Interview with RN #77 on 10/11/18 at 8:34 A.M. verified Resident #11 did not have his Eliquis from 10/02/18 to 10/07/18 due to the medication not being at the facility. RN #77 reported the facility received notice on 09/28/18 from Resident #11's pharmacy of choice that an order was needed to refill the Eliquis. RN #77 reported the facility reached out to Physician #188 on 09/28/18, but the physician did not respond. RN #77 stated Resident #11 ran out of the Eliquis on 10/02/18. RN #77 stated Nurse Practitioner #189 was notified Resident #11 was out of Eliquis on 10/07/18 due to Physician #188 not responding to the request for an order. RN #77 reported NP #189 was able to call in a prescription on 10/07/18. RN #77 confirmed Resident #11's resident representative was able to pick up the resident's medication from his pharmacy of choice on 10/07/18. RN #77 also verified two Medication Aides (#36 and #145) reported they administered Resident #11's Eliquis 5 mg during the period of time the resident did not have Eliquis in the facility. RN #77 also stated Resident #11's Eliquis was not pulled from the emergency box. RN #77 reported the facility was investigating how the Resident #11's Eliquis 5 mg was given on 10/03/18 at 9:00 A.M., 10/04/18 at 9:00 P.M. and on 10/06/18 at 9:00 A.M. since the resident did not have any Eliquis in the facility. RN #77 also reported he did not know why Resident #11 did not receive his Eliquis on 10/08/18 at 9:00 P.M. and on 10/09/18 at 900 A.M. since the medication was back in the facility at that time. Interview with Medication Aide #145 on 10/11/18 at 12:13 P.M. revealed he did not remember giving Resident #11 his Eliquis 5 mg 10/04/18 at 9:00 P.M. and on 10/06/18 at 9:00 A.M Medication Aide #145 reported he was aware of a period of time that Resident #11 did not have his Eliquis in stock. Interview with Medication Aide #36 on 10/11/18 at 12:26 P.M., revealed she administered the resident's Eliquis on 10/03/18 at 9:00 A.M Phone interview with Physician #188's office on 10/11/18 at 12:32 P.M. revealed the physician was out of the office until 10/21/18. Phone interview with Physician #190 on 10/11/18 at 12:39 P.M. revealed he was unable to determine how Resident #11 could have been affected by not receiving his Eliquis from 10/02/18 to 10/07/18. Physician #190 reported he was not aware of any current serious impact to Resident #11 due to him not receiving his Eliquis. Physician #190 reported the possibility of the resident having a clot or issue as a result of him not taking his Eliquis was dependent on his family history and other factors that could have caused the first clot. Interview with the Director of Nursing (DON) on 10/11/18 at 3:30 P.M. reported the facility did not have a medication administration policy that addressed the accuracy of the MAR indicated [REDACTED]. Review of the facility's Medication Administration Scheduling policy dated 01/01/09 revealed no information regarding accuracy of the MAR indicated [REDACTED] 2. Review of Resident #195's medical record revealed the resident was originally admitted on [DATE] and had a re-entry date of 10/08/18. [DIAGNOSES REDACTED]. On 10/09/18 at 6:20 P.M. during review of Resident #195's medical record revealed the code status in the electronic chart was Do Not Resuscitate Comfort Care-Arrest (DNRCC-Arrest). Review of the code status in the paper chart on 10/09/18 at 6:20 P.M. listed the code status as DNRCC-Arrest on the physician's orders [REDACTED]. The chart also contained a red sticker on the spine of the paper chart indicating the resident's code status as DNRCC-Arrest. Neither the electronic chart nor paper chart contained an Ohio DNR identification form signed by the resident or the physician. On 10/10/18, review of the progress notes dated 10/10/18 at 9:43 A.M. revealed a late entry for 10/09/18 at 8:00 A.M. The entry documented the resident had been a DNRCC-Arrest in the hospital and had verbalized uncertainty about continuing the DNRCC-Arrest code status. The note indicated the Form was left to be completed due to resident not being sure if she wanted to still be a DNRCC-Arrest and wanted to wait until her family came in for a visit. Writer stated okay and was educated that staff would have to treat her as a full code in the event that she went into [MEDICAL CONDITION]. Resident verbalized understanding. Review of a telephone order dated 10/09/18 at 6:30 P.M. revealed an order which documented, Change code status to Full Code. On 10/10/18 at 9:59 A.M., review of the electronic health record still listed the resident's code status as DNRCC-Arrest, despite the telephone order in the paper chart dated 10/09/18 at 6:30 P.M. to change the code status to Full Code and the documented conversation with the resident on 10/09/18 at 8:00 A.M. to treat the resident as a full code. Interview on 10/09/18 at 6:20 P.M. with Unit Coordinator (UC) #29 and the director of nursing (DON) verified the resident's paper chart contained a red sticker on the spine label to indicate a DNRCC-Arrest status and that the electronic health record and printed physician's orders [REDACTED]. Both UC #29 and the DON verified the chart did not contain an Ohio DNR form signed by the resident or physician. Interview on 10/10/18 at 9:59 A.M., RN #92 stated when the resident was admitted , the resident voiced uncertainty about maintaining the DNRCC-Arrest code status, so the Ohio DNR identification form was not signed by the resident and was not in the chart. RN #92 verified the paper chart contained a telephone order dated 10/09/18 at 6:30 P.M. to change the code status to full code, but stated the date and time on the order was mistakenly documented incorrectly, as the order to change the code status to full code was not actually obtained and written in the paper chart until the morning of 10/10/18 by RN #92. RN #92 verified the code status designation in the electronic health record still contained the DNRCC-Arrest designation at the time of this interview.

Based on policy review, record review and staff interviews, the facility failed to properly document five resident's advanced directives, specifically their wishes for their code status on a valid form. This affected four residents (#4, #27, #40 and #43 ) of five residents sampled for their Do Not Resuscitate (DNR) documentation. The facility identified 36 residents as having a DNR code status. The resident census was 51. Findings include: A review was conducted on the code status documents on the Ohio Revised Code 3701-62-04 required the facility to document the Resident's code status on the approved Appendix A form. The following four residents were not on the approved Appendix A form: 1. Resident #27 was admitted to the facility on [DATE]. The DNRCC (Do Not Resuscitate Comfort Care) document was signed by the resident and Nurse Practitioner and dated 04/02/18. 2. Resident #43 was admitted to the facility on [DATE]. The DNRCC document was signed by resident and Nurse Practitioner and dated 05/17/18. 3. Resident #40 was admitted to the facility on [DATE]. The DNRCC-Arrest document was signed by the resident and physician and dated 01/22/13. 4. Resident #4 was admitted to the facility on [DATE]. The DNRCC document was signed by the resident and Nurse Practitioner and dated 05/29/18. On 06/13/18 at 1:30 P.M. an interview with the Administrator revealed she had reviewed the Enhanced Information Dissemination Collection and she had not been notified the facility was required to document their residents' code status on Appendix A, which went into effect 02/03/14. Review of the facility policy for Documentation Code - DNR Comfort Care, with an effective date 09/23/08. The purpose was to provide guidelines for the DNR Comfort Care (DNRCC) and DNR Comfort Care Arrest (DNRCC-Arrest) consistent with resident wishes and right of self determination. The policy documented all residents had the right, either directly, through a surrogate or other Advance directive, to refuse or request the withholding of life support initiatives. Each resident's DNR Comfort Care must be established and written within 30 days of admission. The procedure instructed this treatment option is based on the Ohio Administrative Code 3701-62. DNRCC may be either a. DNR Comfort Care (DNRCC) or b. DNR Comfort Care - Arrest (DNRCC-Arrest). All new admissions or their representatives will be asked by nursing or designee if they are participating in the DNRCC or DNRCC-Arrest protocol. If not, they will be provided information for assistance. The nurse and/or designee receiving the DNRCC or DNRCC-Arrest order: a. ascertains all policies are in compliance, b. completes a DNR Comfort Care Form, c. obtains a DNR order signed by the resident's attending physician or Certified Nurse Practitioner (CNP), d. informs other nursing staff on the unit and next shift in report and e. enters this information in the Advanced Directions section of the electronic medical record. This deficiency substantiates Complaint Number OH 268.

Based on record review and staff interview, the facility failed to act on a pharmacy recommendation for a gradual dose reduction of an antipsychotic medication in a timely manner, and failed to attempt a gradual dose reduction (GDR) in the required time frame for one (Resident #6) of five residents reviewed for unnecessary medications. The facility census was 39. Findings include: Review of the medical record for Resident #6 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of the medical record revealed Resident #6 currently had an order for [REDACTED]. Review of the pharmacy recommendation report to the attending physician dated 12/09/16 revealed the pharmacist recommended an evaluation for a gradual dose reduction. The Nurse Practitioner signed the recommendation on 03/16/17 and noted the MD would be inquired about the [MEDICATION NAME]. Review of the Medication Administration Record [REDACTED]. Review of the Consultant Pharmacist's Medication Regimen Review report dated 06/09/17 revealed the pharmacist noted a gradual dose reduction (GDR) evaluation was due by June 2017 for the [MEDICATION NAME] medication. The report also stated any recommendations would be noted on the monthly pharmacy medication regimen review (MRR) summary report. No summary report or note to the physician could be found in the residents chart for June 2017. During an interview on 08/09/17 at 8:49 A.M., the DON provided the pharmacists recommendation report to the attending physician dated 06/09/17. The recommendation stated Resident #6 was receiving 100 mg of [MEDICATION NAME] daily and to evaluate for a gradual dose reduction. The Physician signed on 08/08/17 and agreed to the recommendation and noted to decrease the [MEDICATION NAME] to 50 mg per night. The DON verified the recommendation was not addressed until 08/08/17 after this surveyor intervention. The DON further stated the pharmacist sends her the recommendations via email and she had accidentally missed the attachment for that recommendation for Resident #6. She further confirmed the recommendation was not given to the physician until 08/08/17, approximately two months after the recommendation was made by the pharmacist and over a month after the annual GDR was due for the [MEDICATION NAME]. During an interview on 08/09/17 at 1:45 P.M., the DON verified the pharmacy recommendation report dated 12/09/16 was not addressed by the nurse practitioner until 03/16/17, over three months after the recommendation was made. She further stated there was no other documentation addressing the GDR recommendation for the [MEDICATION NAME] and no documentation showing the physician was inquired about the [MEDICATION NAME] after the nurse practitioner signed the recommendation. Review of the facility policy titled Medication Regimen Review, dated 01/01/09, revealed the policy stated each resident's attending physician would receive a report of the medication review when actual or potential medication related problems are identified by the pharmacist. The policy further stated the report would be faxed to the attending physician's office with a written request for a response documented on the medication review report form. Review of the facility policy titled Chemical Restraint Policy, dated 12/01/16, revealed the policy stated gradual dose reductions would be attempted at a six month interval if not before. The policy further stated the dose reduction would be documented for effectiveness, side effects, etc, and supporting documentation will be noted in the physician progress notes [REDACTED].

Based on record review, observation and staff interview, the facility failed to provide care planned interventions for weight loss to one (#122) of three residents reviewed for nutrition. The facility census was 46. Findings include: Review of Resident # 122's medical record revealed an admission date of [DATE] and had [DIAGNOSES REDACTED]. Review of the resident's assessment dated [DATE] indicated the resident had severe cognitive impairment and required extensive assistance with activities of daily living (ADLs) including eating. Review of a dietary progress note dated 05/06/16 indicated Resident #122 had a significant weight loss of 6.3 % of her body weight in 30 days. The note stated a magic cup (a high calorie nutritional supplement) would be provide to Resident #122 at lunch. Resident #122's plan of care dated 05/06/16 indicated the resident would receive magic cups. The medical record had no documentation of the acceptance of the magic cup. On 06/02/2016 at 12:50 P.M. Resident #122 was observed eating in the dining room. The resident was being fed by staff. The resident had no magic cup offered to her during the meal. Interview on 06/02/16 at 12:55 P.M. Dietary Aide # 10 stated the State tested Nursing Assistants (STNA) usually gets the supplements for the residents that need them. Interview with STNA # 20 at 1:08 P.M. revealed Resident #122 had not been offered a magic cup during the meal and stated she was not sure if Resident # 122 was supposed to have a supplement. STNA #20 stated she thought the nurse provided it to the residents. Interview on 06/02/2016 at 3:57 P.M. with Dietetic Technician # 35 stated she was not sure but thought the dietary aide provide the magic cups. DTR #35 further stated the accepted of the magic cup is not recorded because it is not a physician order.

Based on observation, staff interview, and record review the facility failed to provide a clean and sanitary kitchen. This had the potential to affect all residents residing in the facility. The census was 51. Findings include: Observation of the kitchen on 03/16/15 at 10:02 A.M. revealed multiple areas of dried, white substance, various in sizes, on the outside of refrigerator R5. Further observation revealed the entire handle of the salad dessert refrigerator was covered in a dry, white substance. Interview with Dietary Supervisor (DS) #108 at the time of the observation confirmed the substance on refrigerator R5 and on the salad dessert refrigerator. Dietary supervisor #108 revealed the cook is supposed to clean the refrigerators at the end of his/her shift. Dietary supervisor #108 indicated there was no log kept regarding cleaning of the refrigerators. Observation of R6a freezer on 03/16/15 at 10:08 A.M. revealed approximately six diced carrots and a piece of triangular-shaped green paper measuring approximately 2 inches by 3 inches lying on the bottom shelf of the freezer. Further observations revealed white crumbs and a clear, semi-frozen liquid both covering approximately half of the bottom of the freezer. Interview with DS #108 at the time of the observation confirmed the items and the clear, semi-frozen liquid on the bottom shelf of R6a freezer. Dietary supervisor #108 revealed the freezer is supposed to be cleaned once a week on Sunday. Observation of the environment around the steam table on 03/16/15 at 10:18 A.M. revealed a thick dust build up and a medium sized pile of crumbs on the floor near a cement block that had an outlet built into it. A piece of wilted lettuce, thick dust buildup, and a medium sized pile of crumbs were also noted near a wheel of the steam table. Further observation at 11:24 A.M. revealed dirt buildup and crumbs covering a large area on the floor located left of the food heater and right of the wall Interview with DS #108 at the time of the observations confirmed the dust buildup, crumbs, and wilted lettuce on the floor underneath the steam table and the dirt buildup and crumbs on the floor located left of the food heater and right of the wall. On 03/16/15 at 11:27 A.M. observations revealed thick dust buildup on the wall directly across from the ductwork hanging from the ceiling. Thick dust buildup was noted on the top of a shelf that was up against the wall. Further observation at 11:31 A.M. revealed thick dust buildup on a yellow Mcgill retractable extension cord hanging from the ceiling beside the ductwork. This retractable extension cord was hanging over a rack with empty trays on it. The ductwork facing inwards toward the serving area revealed thick, black dust covering the vents and also covering a large area of the ceiling. Interview with DS #108 at the time of the observations revealed the dust was present on the ductwork and walls. Dietary Supervisor #108 stated the same company who cleans the hood range cleans the vents twice a month. Further interview at 11:38 A.M. revealed the retractable extension cord had a thick dust buildup on it and that it was hanging over a rack holding the room trays. Interview with Dietary Manager (DM) #109 on 03/18/15 at 2:16 P.M. revealed there was no policy regarding cleaning the kitchen, appliances, or air ducts. DM #109 revealed the kitchen staff are responsible for cleaning the kitchen and the appliances. DM #109 stated lettuce was last served for dinner the day before on 03/17/15. DM #109 stated they did not maintain logs for cleaning the kitchen or the appliances. DM #109 revealed the vents are supposed to be cleaned weekly, but were last cleaned on 02/14/15.

Based on observations, staff interviews, and policy reviews, the facility failed to dispose of outdated medications and failed to record the date when opened on open vials of injectable medications. This had the potential to affect 13 of 51 current residents and had the potential to affect all residents who receive the Tuberculin skin test. Findings include: On 03/19/15 at 10:35 A.M., observations in the first floor rehab unit medication room revealed two bottles of Stool Softener with an expiration date of 11/14, one bottle of Banophen with an expiration date of 2/15, three bottles of Aspirin 325 mg with an expiration date of 02/15, one bottle of Calcium 500 mg with Vitamin D 200 IU with an expiration date of 01/14, and one can of Granulex spray with an expiration date of 06/13. At 10:45 A.M. observations in the basement stock room revealed two bottles of Aspirin 325 mg with an expiration date of 12/13, three bottles of Aspirin 325 mg with an expiration date of 02/15, one bottle of stool softener with an expiration date of 11/14, one bottle of Banophen 25 mg with an expiration date of 02/15, and two bottles of Calcium 500 mg with Vitamin D 200 IU with an expiration date of 12/14. At 10:54 A.M., observations in the second floor medication room revealed one open vial of Tuberculin skin testing solution with no date when opened. At the time of the findings, an interview with Registered Nurse (RN) #76 confirmed the expired medications and the vial of tuberculin testing solution with no date when opened. RN #76 stated the expired medications should have been disposed of and the Tuberculin testing solution should have a date when opened noted on the open vial. At 10:55 A.M., an interview with Pharmacist #200 revealed a complete medication storage check of the medication rooms was done every six months but the Pharmacist did not check the storage room for over the counter medications. That was the responsibility of the facility to check for out dated medications in the storage room. The Facility Policy dated 01/01/09 revealed outdated drugs and biologicals would be destroyed as allowed by state and federal law. The Drug Storage policy dated 10/2010 revealed all expired medications should be removed from medication carts or cupboards promptly. The refrigerator Storage Policy dated 10/2010 revealed PPD - TB testing agent need a date when opened and discarded within 28 days of the date when opened.

Based on record review and staff interviews, the facility staff failed to have complete documentation regarding assessments and interventions for a resident who had low blood sugar. This affected one Resident #50 out of five residents sampled for unnecessary medications. The facility census was 51. Findings included: Resident #50 was originally admitted to the facility on [DATE] and readmitted on [DATE] with the [DIAGNOSES REDACTED]. Review of Resident #50's electronic Medication Administration Record [REDACTED].M.) and 28 on 02/21/15 (9:00 A.M.). The documentation of the resident's signs or symptoms of [DIAGNOSES REDACTED] or the interventions attempted were not documented thoroughly. Review of the physician orders [REDACTED]. Review of the care plan for diabetes for Resident #50 had interventions to include assessing the resident for signs or symptoms of hypoclycemia or [MEDICAL CONDITION]. The medical record was silent for assessment of Resident #50 when he had episodes of low blood sugar. A phone interview was conducted on 03/19/15 at 2:54 P.M. with Registered Nurse (RN) #110. She stated each time Resident #50's blood sugar was low he was given juice and peanut butter crackers. She stated she observed no signs of [DIAGNOSES REDACTED] and rechecked the blood sugar with results in the 70's. She stated she did not call the physician due to the blood sugar staying up after the resident was given juice and crackers. She also stated she had not documented the interventions or the recheck of the resident's blood sugar to show that it was within a normal range. Review of the standing orders for blood sugars revealed an order to notify the physician for blood sugar readings less than 60 or greater than 400 unless the physician had individualized parameters for notification.

Based on record review and staff interview the facility failed to develop a care plan for anticoagulation use. This affected one (Resident #29) of five residents reviewed for unnecessary medications. The census was 51. Findings include: Review of the medical chart for Resident #29 revealed an admission on 02/11/15 with [DIAGNOSES REDACTED]. Review of the physician order [REDACTED]. Review of the care plans for Resident #29 revealed the facility did not have a care plan in place for anticoagulation/[MEDICATION NAME] use. Interview with the Director of Nursing (DON) on 03/18/15 at 12:11 P.M. revealed they had failed to initiate a care plan for Resident #29 for anticoagulation/[MEDICATION NAME] use.

Based on record review and staff interviews, the facility failed to notify the physician regarding a resident who had low blood sugar. This affected one Resident #50 out of five residents sampled for unnecessary medications. The facility census was 51. Findings include: Resident #50 was originally admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #50's electronic Medication Administration Record [REDACTED].M.) and 28 on 02/21/15 (9:00 A.M.). There was no documentation the resident's physician was notified. Review of the physician orders [REDACTED].#50. An interview was conducted with Registered Nurse (RN) #110 on 03/19/15 at 2:54 P.M. by phone. She stated each time Resident #50's blood sugar was low he was given juice and peanut butter crackers. She stated she observed no signs of [DIAGNOSES REDACTED] and rechecked the blood sugar after treatment with results in the 70's. She stated she did not call the physician due to the blood sugar staying up after the resident was given juice and crackers. Review of the standing orders for blood sugars revealed to notify the physician for blood sugar readings less than 60 or greater than 400 unless the physician had individualized parameters for notification.

Based on review of posted instructions, observation and interview the facility failed to ensure foods were labeled with expiration dates and discarded when expired and failed to ensure the sanitizer in the three compartment sink was at the correct concentration to effectively sanitize pot and pans. This had the potential to affect all 45 of the facility's 46 residents that receive meals from the facility's kitchen. Findings include: During tour of the kitchen on 12/02/13 at 10:45 A.M. one half full box of thawed mighty shakes were observed in a reach in cooler. There was no date on the mighty shakes to indicate when the shakes had been thawed. The label on the shakes indicated the shakes are good for 14 days after they have been thawed. A second half full box of mighty shakes was also in the reach in. This second box was dated 09/27/13. The label on the shakes indicated the shakes are good for 14 days after they have been thawed. There were approximately 30 shakes in each box. These observations were verified by Dietary Staff (DS) #10 who stated the all the mighty shakes would be discarded. Also during tour of the kitchen on 12/02/13 the three compartment sink was in use. Pot and pans with sanitizing solution were in the sanitizing compartment. When checked by DS #10 the concentration of sanitizer measured less than 200 parts per million (ppm). The instructions on the wall above the sink indicated the concentration should be 200 ppm to effectively sanitize. DS#10 verified the sanitizer was not at the correct concentration.